Retrograde Pyelography

THE method of procedure of retrograde pyelography in Jefferson Hospital has not varied since 1912, when Professor Willis F. Manges first described the advantages of injecting the opaque solution into the renal pelvis under fluoroscopic control. Every retrograde pyelographic study at Jefferson Hospital since that date has been done under careful fluoroscopic control. The term “pyeloscopy” is used for the sake of brevity. Dr. Manges in his paper on this subject says: “Pyeloscopy is a preliminary to pyelography, and adds, we believe, distinctly to the comfort of the patient, as well as to the safety and accuracy of the entire procedure.” This statement is just as applicable to-day as it was then. Excretion urography has not supplanted retrograde pyelography as some would have us believe, but has made retrograde pyelography the more accurate procedure in roentgenologic diagnosis of renal pathology. The highest degree of efficiency of retrograde pyelography can be attained only by practising pyeloscopy. Dr. Manges' reasons for asking to observe the injection fluoroscopically were that frequently they were unsuccessful in obtaining satisfactory pyelograms—patients were having a great deal of pain from over-distention—and that because of frequent re-examination the work of his department was unnecessarily increased. We may add that if excretion urography does not give us the required information, we look to retrograde pyelography as the final court of appeal. The advantage of pyeloscopy in such cases remams undisputed. There should always be a preliminary radiographic examination of the entire urinary tract. The films should be of such quality as to show the outline of the kidneys—their size and position—and any calculus or other density in the region of the kidneys, ureters, or bladder. Previous to the day of the examination, the patient is instructed to partake of a light supper, and later in the evening one ounce of castor oil. On the morning of the examination, a simple soap-suds enema is administered. No breakfast is served. The preliminary radiographic examination is then made. There have been quite a few cystoscopic tables that are equipped with the Potter-Bucky diaphragm and x-ray tube for making pyelographic exposures. Recently, there has been constructed a cystoscopic table which permits fluoroscopic observation of the injection. We have such a table at Jefferson, and it is used frequently. We still adhere, however, to the x-ray table that combines the advantages of the fluoroscope and Potter-Bucky diaphragm, in any position from the Trendelenburg to the erect. There is no real objection to removing the patient from the cystoscopic table to the fluoroscopic one with the catheters in the ureters after the cystoscope has been removed.